Gut-Directed Hypnosis: Comparing the Manchester Protocol and North Carolina Approach with HypnoIBS®

Gut-directed hypnotherapy has one of the strongest research foundations of any clinical application of hypnosis. Since the pioneering work of Professor Peter Whorwell and colleagues in the 1980s, researchers have demonstrated that hypnosis can help people with Irritable Bowel Syndrome (IBS) experience improvements in gastrointestinal symptoms, quality of life and everyday functioning.

Two approaches have been particularly influential: the Manchester Protocol, developed in the UK, and the North Carolina Protocol, developed in the United States. Although both use hypnosis to work with the relationship between the brain and digestive system, they differ in their structure, use of scripts and degree of individualisation.

My own approach, HypnoIBS®, developed from an interest in this research, my personal experience of living with IBS and my clinical work with clients experiencing gastrointestinal symptoms. It draws on established gut-directed hypnotherapy research while incorporating CBT-hypnosis and mindfulness-hypnosis.

Both Cognitive Behavioural Therapy (CBT) and mindfulness-based interventions have substantial research backgrounds in their own right, including evidence supporting their use with IBS (Laird et al., 2017; Gaylord et al., 2011). This provides an additional rationale for exploring how their principles can be incorporated into gut-directed hypnosis, although evidence for the individual approaches does not automatically establish the effectiveness of a particular combined programme.

For practitioners interested in working with IBS, understanding these different approaches offers an opportunity to explore the research behind gut-directed hypnotherapy and consider how different therapeutic methods can be brought together within clinical practice.

Gut-Directed Hypnosis: Comparing the Manchester Protocol and North Carolina Approach with HypnoIBS®: What Is Gut-Directed Hypnotherapy?

Gut-directed hypnotherapy is a psychological treatment that uses hypnosis, therapeutic suggestions and imagery to influence the relationship between the brain and digestive system. It is used to help people with IBS manage symptoms such as abdominal pain, bloating, diarrhoea, constipation and gastrointestinal discomfort.

IBS is classified as a disorder of gut–brain interaction. The digestive system and brain communicate continuously through a complex network involving the nervous system, hormones, immune processes and other physiological mechanisms. Differences in how these systems interact can influence bowel functioning, visceral sensitivity and the way gastrointestinal sensations are experienced.

Gut-directed hypnosis works with these processes through suggestions and imagery aimed at improving digestive comfort, reducing symptom sensitivity and helping clients develop greater confidence in their body's functioning.

A client might, for example, be encouraged to imagine warmth spreading through the abdomen, the digestive system becoming calmer or the bowel functioning more smoothly. Other interventions might focus on responding differently to physical sensations, reducing anticipatory anxiety or developing confidence in situations that have become difficult because of IBS.

Gut-directed hypnotherapy is supported by several decades of clinical research, although different researchers have developed somewhat different ways of delivering treatment.

The Manchester Protocol: The Foundations of Gut-Directed Hypnotherapy Research

The Manchester Protocol was developed by Professor Peter Whorwell and colleagues during the 1980s. Their original controlled trial, published in The Lancet in 1984, demonstrated significant improvements in patients with severe IBS who had not responded adequately to conventional medical treatment (Whorwell et al., 1984).

This was an important development because IBS had often proved difficult to treat, particularly among patients experiencing persistent and debilitating symptoms. The study helped establish hypnosis as a serious area of clinical investigation within gastroenterology.

The Manchester Protocol combines gut-directed hypnotic suggestions with therapeutic discussion, psychoeducation and attention to the client's individual experience of IBS.

Hypnotic imagery is a central component. Clients may be guided to imagine soothing warmth in the abdomen or comfortable, coordinated digestive functioning. Suggestions can also address symptom sensitivity, confidence and the client's ability to manage everyday situations.

Importantly, the Manchester approach is not simply a standardised script. Practitioners explore the client's symptoms, concerns and experiences, adapting interventions to individual needs. Psychological and lifestyle factors may also be considered as part of the therapeutic process (Gonsalkorale, 2006).

Traditionally, the Manchester Protocol has involved approximately twelve sessions, usually lasting between 30 and 60 minutes. Recordings are used to support practice between appointments.

Research has also examined whether fewer sessions can produce comparable results. Hasan et al. (2021) compared six and twelve sessions of gut-focused hypnotherapy in 448 patients with refractory IBS. The researchers found that six sessions were non-inferior to twelve in terms of improvements in IBS symptom severity.

This is particularly interesting for practitioners considering how to balance treatment intensity, accessibility and the practical needs of clients.

The North Carolina Protocol: Standardised Gut-Directed Hypnosis

The North Carolina Protocol was developed by Professor Olafur Palsson and colleagues at the University of North Carolina at Chapel Hill.

Although it shares the Manchester Protocol's emphasis on the gut–brain connection and hypnotic suggestions for gastrointestinal comfort, its treatment structure is quite different.

The North Carolina Protocol consists of seven sessions, generally delivered every two weeks. Each session follows a predetermined hypnosis script, with practitioners instructed to deliver the hypnotic content verbatim.

The scripts incorporate hypnotic relaxation, gut-directed imagery and suggestions aimed at improving digestive functioning and reducing symptom sensitivity. Clients are also encouraged to practise regularly between appointments using recordings.

The standardised nature of the programme is one of its defining characteristics. Because the hypnotic content is consistent, researchers can examine outcomes using a clearly defined intervention that can be reproduced across different settings.

Palsson (2006) described the development of the protocol and reported that two published studies had found benefits among more than 80% of participants.

Standardisation also has potential advantages for practitioners. A carefully developed sequence of scripts provides a clear structure and ensures that important therapeutic elements are included.

At the same time, fixed scripts offer less opportunity to adapt the hypnotic content to the individual client's language, preferences and experiences. This represents an important distinction between the North Carolina approach and more individually tailored forms of gut-directed hypnotherapy.

Developing HypnoIBS®: From Personal Experience to Clinical Practice

My interest in gut-directed hypnotherapy began with my own long-term experience of IBS, alongside my growing work with clients experiencing gastrointestinal symptoms.

Having lived with IBS for many years, I was particularly interested in the relationship between physical symptoms, the nervous system and the ways that symptoms can affect everyday life. IBS can influence decisions about travelling, eating out, working and socialising, and the anticipation of symptoms can become almost as disruptive as the symptoms themselves.

As with most areas of therapeutic work, I felt it was important to explore an approach personally before attempting to use it with clients. This meant going back to the original research rather than simply relying on descriptions of gut-directed hypnosis or claims about its effectiveness.

I found the research particularly encouraging. The early Manchester studies demonstrated substantial improvements among people experiencing severe and persistent IBS, while subsequent research helped establish that these benefits could extend beyond gastrointestinal symptoms to improvements in quality of life and everyday functioning.

I was also interested in the differences between the Manchester and North Carolina approaches. Both had contributed valuable research, but they offered quite different ways of structuring treatment. The North Carolina Protocol demonstrated the benefits of a carefully standardised programme, while the Manchester approach placed greater emphasis on individualised therapeutic work.

It was against this background that I developed HypnoIBS®.

I wanted to retain the central principles of gut-directed hypnotherapy while incorporating two other approaches that I had found particularly valuable in clinical practice: CBT-hypnosis and mindfulness-hypnosis.

Bringing CBT-Hypnosis into Gut-Directed Hypnotherapy

CBT is particularly relevant to IBS because of the relationships between physical sensations, thoughts, emotions and behaviour. Research has demonstrated that CBT-based psychological interventions can improve IBS symptoms and functioning (Laird et al., 2017).

A CBT-informed approach helps clients recognise how different parts of their experience can influence one another. For example, someone who experiences abdominal discomfort before travelling might begin anticipating that they will urgently need a toilet. This expectation can increase anxiety, heighten attention to gastrointestinal sensations and lead to avoidance of journeys.

The familiar CBT triangle, linking thoughts, emotions and behaviours, provides a useful starting point for exploring these patterns, while recognising that physical sensations are also central to the experience of IBS.

Within CBT-hypnosis, practitioners can help clients identify situations that trigger particular responses, explore the thoughts and expectations associated with them, and use hypnosis to practise different outcomes.

A client who has become anxious about travelling might use hypnotic imagery to rehearse preparing for a journey, travelling comfortably and responding more confidently to gastrointestinal sensations. The aim is to help the client develop new expectations and behavioural possibilities, rather than repeatedly rehearsing the difficulties they anticipate.

Hypnosis can provide a focused, absorbed state in which clients can engage with imagery and suggestions while mentally practising changes they want to make in everyday life.

Bringing Mindfulness-Hypnosis into Gut-Directed Hypnotherapy

Mindfulness-based approaches are also relevant to IBS, particularly because of the role that attention, symptom monitoring and emotional responses can play in the experience of gastrointestinal discomfort.

Research has demonstrated that mindfulness training can improve IBS symptom severity and quality of life. For example, Gaylord et al. (2011) found improvements in IBS symptoms among women who participated in a mindfulness-based intervention.

Mindfulness encourages people to develop greater awareness of their experiences while changing how they respond to thoughts, emotions and physical sensations.

For someone with IBS, this can be particularly useful when attention has become strongly focused on gastrointestinal sensations or the possibility of symptoms occurring.

Mindfulness-hypnosis brings these principles into hypnotic work. Rather than attempting to suppress sensations or force the digestive system to behave in a particular way, suggestions can encourage a more flexible relationship with physical experiences.

A client might be guided to imagine sensations passing through awareness, to develop a sense of physical space and comfort, or to shift attention towards other aspects of their experience.

Mindfulness-hypnosis can also support clients in recognising that the presence of a sensation does not necessarily mean that symptoms will escalate or that an anticipated difficulty will occur.

For me, this was an important addition to gut-directed hypnotherapy because IBS can involve not only uncomfortable physical symptoms, but also considerable anticipation, monitoring and concern about what those symptoms might mean.

Structuring HypnoIBS® Around Four Core Sessions

Another consideration in developing HypnoIBS® was the practical structure of treatment.

Many people with IBS have already spent considerable time and money trying to manage their symptoms. A lengthy course of appointments can present financial and practical difficulties, particularly for clients who are already struggling with work, travel or everyday activities.

I wanted to develop a framework that provided enough time for meaningful therapeutic work while keeping the initial commitment manageable.

HypnoIBS® therefore uses four core sessions, with appointments generally recommended to last between 60 and 90 minutes. These longer appointments allow time for therapeutic discussion, psychoeducation, CBT-informed and mindfulness-informed work, and substantial gut-directed hypnosis.

Clients are also encouraged to use recordings between sessions, supporting regular practice and helping them develop confidence in using hypnosis independently.

The four sessions provide a framework rather than a fixed limit. Additional appointments can be offered according to individual needs, and practitioners are encouraged to adapt their work to the client's symptoms, experiences and responses.

The HypnoIBS® four-session framework has not itself been evaluated in a comparative clinical trial. It is a practitioner treatment model informed by the wider research on gut-directed hypnosis and the psychological approaches incorporated within it.

Comparing the Manchester, North Carolina and HypnoIBS® Approaches

Although the three approaches share a foundation in gut-directed hypnosis, they differ in how treatment is structured and the techniques practitioners are encouraged to use.

The North Carolina Protocol is highly standardised, using seven predetermined hypnosis scripts. This makes it particularly suitable for consistent delivery and research evaluation.

The Manchester Protocol uses a more individualised approach, incorporating discussion, psychoeducation and hypnotic interventions adapted to the client's symptoms and circumstances. Treatment has traditionally involved twelve shorter appointments, although six-session programmes have also been studied.

With HypnoIBS®, I wanted to retain the individualised nature of gut-directed hypnosis while placing greater emphasis on CBT-hypnosis and mindfulness-hypnosis. The four-session framework allows practitioners to address gastrointestinal symptoms alongside patterns of thinking, attention, emotional responses and behaviour.

All three approaches recognise the importance of independent practice. Recordings help clients reinforce hypnotic suggestions between appointments and develop confidence in using the techniques themselves.

The differences between the approaches illustrate the range of ways gut-directed hypnotherapy can be delivered. A standardised programme provides consistency, while a more individualised approach allows practitioners to respond to the client's particular symptoms and experiences.

Why Does the Structure of Gut-Directed Hypnotherapy Matter?

When considering gut-directed hypnotherapy for IBS, the number and length of appointments are important practical considerations.

A programme involving twelve weekly appointments requires a different commitment from one involving seven fortnightly sessions or four longer appointments. Clients may need to consider work, travel, family responsibilities and treatment costs, particularly when accessing private therapy.

Session length also influences how practitioners organise therapeutic work. Shorter appointments may allow for repeated hypnotic practice over a longer period, while longer appointments can provide more opportunities for discussion, psychoeducation and individualised interventions within each meeting.

Home recordings are an important feature of all three approaches, extending therapeutic practice beyond the appointment itself. Regular independent practice can help clients reinforce suggestions, develop familiarity with hypnosis and build confidence in using the techniques.

From a practitioner's perspective, understanding these structural differences can help inform decisions about treatment planning, client expectations and how to balance a clear therapeutic framework with responsiveness to individual needs.

What Does the Research Tell Us About Gut-Directed Hypnotherapy?

The research supporting gut-directed hypnotherapy has developed considerably since the original Manchester studies.

Early trials demonstrated that hypnosis could produce meaningful improvements among people with severe IBS who had not responded adequately to conventional treatment. Subsequent studies using different protocols, including the North Carolina approach, provided further evidence of improvements in gastrointestinal symptoms and quality of life.

The development of standardised protocols has been particularly valuable in research because it allows investigators to evaluate clearly defined interventions. At the same time, studies using individualised approaches have demonstrated the potential value of adapting therapeutic work to the client's circumstances.

Research has also explored treatment duration, including the Manchester study comparing six and twelve sessions. These findings contribute to our understanding of how gut-directed hypnosis can be delivered, although outcomes from one protocol cannot automatically be assumed to apply to another.

CBT and mindfulness-based interventions have also been investigated independently for IBS. Their evidence bases provide a rationale for considering how their principles might complement gut-directed hypnosis, but further research would be needed to determine whether particular combinations offer additional benefits.

For practitioners, this wider body of research provides a foundation for learning gut-directed hypnotherapy while encouraging critical thinking about how different interventions are selected and applied.

What Can Practitioners Learn from These Different Approaches?

The development of gut-directed hypnotherapy demonstrates the value of both structured treatment protocols and individualised clinical practice.

The Manchester Protocol established an important foundation for research into hypnosis for IBS, while the North Carolina Protocol demonstrated how a standardised programme could be delivered consistently and evaluated scientifically.

With HypnoIBS®, my aim has been to build on this research while bringing together the principles of CBT-hypnosis and mindfulness-hypnosis that I have found particularly valuable in clinical practice.

I believe there are advantages to learning a defined therapeutic protocol. It provides structure, supports confidence and helps practitioners develop familiarity with the therapeutic process. However, developing a broader understanding of psychological and hypnotherapeutic techniques also allows practitioners to respond more flexibly to clients whose symptoms, experiences and needs may be very different.

For me, one of the most important aspects of working with IBS is recognising that two clients with similar gastrointestinal symptoms may experience them in very different ways. One may be particularly affected by anxiety about leaving home, another by constant monitoring of physical sensations, and another by the impact of symptoms on work or relationships.

Understanding these differences allows practitioners to move beyond delivering the same hypnotic suggestions to every client and develop interventions that are more closely connected to the individual's experience.

Study Gut-Directed Hypnotherapy with HypnoIBS®

For practitioners interested in developing their skills in gut-directed hypnotherapy, HypnoIBS® provides advanced training grounded in research and clinical practice.

The course includes detailed teaching, practical demonstrations, hypnosis scripts, client resources and guidance on applying the approach confidently and flexibly within your own practice.

Find out more about HypnoIBS® Gut-directed Hypnotherapy Training

Gut-Directed Hypnosis: Comparing the Manchester Protocol and North Carolina Approach with HypnoIBS®: Frequently Asked Questions

What is the difference between the Manchester and North Carolina protocols?

The Manchester Protocol uses a gut-directed hypnotherapy framework that allows treatment to be adapted to the client's individual needs. The North Carolina Protocol uses seven predetermined hypnosis scripts designed for consistent delivery. Both have contributed to the evidence supporting hypnosis for IBS.

How many sessions are involved in gut-directed hypnotherapy?

The number of sessions depends on the approach. The Manchester Protocol has traditionally involved twelve appointments, although six-session programmes have also been studied. The North Carolina Protocol uses seven sessions, while HypnoIBS® uses four longer core sessions, with additional appointments according to individual needs.

What is CBT-hypnosis for IBS?

CBT-hypnosis combines principles of Cognitive Behavioural Therapy with hypnotic techniques. It can help clients identify relationships between thoughts, emotions, physical sensations and behaviour, then use hypnosis to rehearse different responses and more confident outcomes.

What is mindfulness-hypnosis for IBS?

Mindfulness-hypnosis incorporates mindfulness principles into hypnotic work. It can help clients develop greater flexibility in how they direct attention and respond to gastrointestinal sensations, thoughts and concerns about symptoms.

Is gut-directed hypnotherapy supported by research?

Yes. Gut-directed hypnotherapy has been investigated in clinical studies for more than forty years, with research demonstrating improvements in IBS symptoms and quality of life. The Manchester and North Carolina protocols have both contributed to this evidence base.

References

Gaylord, S. A., Palsson, O. S., Garland, E. L., Faurot, K. R., Coble, R. S., Mann, J. D., Frey, W., Leniek, K., & Whitehead, W. E. (2011). Mindfulness training reduces the severity of irritable bowel syndrome in women: Results of a randomized controlled trial. The American Journal of Gastroenterology, 106(9), 1678–1688. https://doi.org/10.1038/ajg.2011.184

Gonsalkorale, W. M. (2006). Gut-directed hypnotherapy: The Manchester approach for treatment of irritable bowel syndrome. International Journal of Clinical and Experimental Hypnosis, 54(1), 27–50. https://doi.org/10.1080/00207140500323030

Hasan, S. S., Whorwell, P. J., Miller, V., Morris, J., & Vasant, D. H. (2021). Six vs 12 sessions of gut-focused hypnotherapy for irritable bowel syndrome: A randomized trial. Gastroenterology, 160(7), 2605–2607.e3. https://doi.org/10.1053/j.gastro.2021.02.058

Laird, K. T., Tanner-Smith, E. E., Russell, A. C., Hollon, S. D., & Walker, L. S. (2017). Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clinical Gastroenterology and Hepatology, 15(7), 937–947.e4. https://doi.org/10.1016/j.cgh.2016.11.020

Palsson, O. S. (2006). Standardized hypnosis treatment for irritable bowel syndrome: The North Carolina protocol. International Journal of Clinical and Experimental Hypnosis, 54(1), 51–64. https://doi.org/10.1080/00207140500322933

Whorwell, P. J., Prior, A., & Faragher, E. B. (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. The Lancet, 2(8414), 1232–1234. https://doi.org/10.1016/S0140-6736(84)92793-4